Co-Occurring Diagnosis
DEMOGRAPHIC INFORMATION /
Plan name:
Study Leader Name: Title:
Telephone Number: E-mail Address:
Name of Project/Study: Co-Occurring Diagnosis
Type of Study:
Clinical Non-clinical
Collaborative HEDIS / Section to be completed by HSAG
Year 1 Validation Initial Submission Resubmission
Year 2 Validation Initial Submission Resubmission
Year 3 Validation Initial Submission Resubmission

Baseline Assessment Remeasurement 1
Remeasurement 2 Remeasurement 3

Year 1 validated through Step
Year 2 validated through Step
Year 3 validated through Step
Type of Delivery System:
Date of Study: 01/01/06 to 12/31/08
Number of Medicaid Members Served by plan:
Number of Medicaid Members in Project/Study:
Submission Date:
Page C-22
Co-Occurring Diagnosis
A. Activity I: Choose the study topic. PIP topics should target improvement in relevant areas of services and reflect the population in terms of demographic characteristics, prevalence of disease, and the potential consequences (risks) of disease. Topics may be derived from utilization data (ICD-9 or CPT coding data related to diagnoses and procedures; NDC codes for medications; HCPC codes for medications, medical supplies, and medical equipment; adverse events; admissions; readmissions; etc.); grievances and appeals data; survey data; provider access or appointment availability data; member characteristics data such as race/ethnicity/language; other fee-for-service data; or local or national data related to Medicaid risk populations. The goal of the project should be to improve processes and outcomes of health care or services to have a potentially significant impact on member health, functional status, or satisfaction. The topic may be specified by the state Medicaid agency or CMS, or it may be based on input from members. Over time, topics must cover a broad spectrum of key aspects of member care and services, including clinical and non-clinical areas, and should include all enrolled populations (i.e., certain subsets of members should not be consistently excluded from studies). /
Study topic:
The overall objective of the Co-Occurring Diagnosis PIP is to improve the quality of discharge planning for members with co-occurring diagnosis. “Member” is defined as being enrolled in the program at the time of discharge or being eligible for plan benefits at the time of discharge. The target population for this PIP is members with co-occurring diagnoses (COD) discharged after an inpatient stay – both acute psychiatric hospitalizations and residential treatment facility admissions. Members with special health care needs were not excluded from the study.
There has been increasing concern about the quality of care delivered to consumers with co-morbid psychiatric and substance abuse disorders. Most experts agree that “only integrated treatment” will be cost effective in treating dually diagnosed individuals (Hegner, 1998). Nationally, however, mental health and substance related disorders treatment often exist in separate, uncoordinated systems. Not only is this a national issue but also one affecting the Medicaid population. The plan has received qualitative feedback internally from staff, as well as from external providers and advocates suggesting that members experience difficulty accessing treatment, receives psychiatric diagnoses inappropriately in order to access services, and do not always receive treatment and appropriate discharge plans related to substance abuse when hospitalized in psychiatric facilities.
There is considerable reason to be concerned about individuals with dual psychiatric and substance related disorders, often referred to as dually diagnosed. The past several decades has witnessed a growing population of dually diagnosed individuals related to de-institutionalization, increased availability of drugs, and changing social and economic conditions (Hegner, 1998). The National Co-morbidity Survey (NCS) indicated that individuals with mental illness are at least twice as likely to abuse drugs including alcohol as individuals with no mental illness (Kessler, 1994). Research has demonstrated that dually diagnosed individuals have a greater tendency for psychiatric relapse and re-hospitalization (Drake & Mueser, 1996). Dually diagnosed individuals also are more likely to experience divorce, social isolation, unemployment, poverty, homelessness, crime and incarceration, and violence (Drake & Mueser, 1996; Kessler, 1994).
In any twelve-month period, an estimated 10 million people throughout the United States have a combination of at least one mental health and substance use disorder (SAMHSA, 2000). There are three million individuals with co-occurring disorders having at least three disorders and one million people have four or more. (National Health Policy Forum, 1998). People with serious mental illness are 4-5 times as likely to develop a substance related disorder as the general population. (U.S. Department of Health and Human Services, 2002).
Youth and Co-Occurring Disorders
  Approximately half of all adolescents receiving mental health services have a co-occurring substance use disorder, and as many as 75-80 percent of youth in inpatient substance related disorders treatment programs have a mental health disorder. (Greenbaum, Foster-Johnson, & Petrila, 1996)
  Children whose parents abuse alcohol or drugs and children with serious emotional disorders are at an increased risk of developing co-occurring substance use and mental health disorders (NACoA, 1998 and SAMHSA, 1999).
  The presence of ADHD, in particular, worsens the prognosis of both the substance use disorder and the conduct disorder, increasing the likelihood of these persisting into adulthood. (Crowley & Riggs, 1999)
  A common sequence of events for adolescents who are at risk for developing co-occurring disorders include 1) trauma 2) early emotional problems 3) personality immaturity or disorder 4) self-medication with alcohol or other drug 5) school and family problems and criminal justice involvement. (Pepper, 2002)
Importance of Discharge Planning for Members with Co-Occurring Diagnosis
In the late 1970s, practitioners began to recognize that the presence of substance related disorders in combination with mental disorders had profound and troubling implications for treatment outcomes. This growing awareness has culminated in today’s emphasis on the need to recognize and address the interrelationship of these disorders through new approaches and appropriate adaptations of traditional treatment. In the decades from the 1970s to the present, substance related disorders treatment programs typically reported that 50 to 75 percent of their clients had COD, while corresponding mental-health settings cited proportions of 20 to 50 percent. During the same period of time, a body of knowledge has evolved that clarifies the treatment challenges presented by the combination of substance abuse and mental disorders and illuminates the likelihood of poorer outcomes for such clients in the absence of targeted treatment efforts. A carefully developed discharge plan, produced in collaboration with the client, will identify and relate client needs to community resources, ensuring the supports needed to sustain the progress achieved in treatment. Continuity of care refers to coordination of care as clients move across different service systems and is characterized by three features: consistency among primary treatment activities and ancillary services, seamless transitions across levels of care (e.g., from residential to outpatient treatment), and coordination of present with past treatment episodes. Because both substance abuse and mental disorders typically are long-term chronic disorders, continuity of care is critical; the challenge in any system of care is to institute mechanisms to ensure that all individuals with COD experience the benefits of continuity of care
On April 2, 2005, the plan completed a study in response to concerns about the treatment of members with both psychiatric and substance abuse/dependence diagnoses (i.e., co-occurring diagnoses), using data collected from discharges that occurred between October 1, 2003 and January 1, 2004. The study, which included an examination of claims data and a random sample of plan discharge summaries of members with co-occurring diagnoses, revealed the following findings:
§  Private inpatient facilities: 34 percent of members were referred for any substance related disorders follow, including 12-Step groups; 32 percent were referred for a combination of substance related disorders and psychiatric services.
§  RMHIs: 15 percent of members were referred for substance related disorders follow; 10 percent were referred for a combination of substance related disorders and psychiatric services.
The findings from April 2, 2005 study report supported implementation of an ongoing plan quality improvement activity aimed at improving the quality of care for members with COD. The Dual Diagnosis PIP was approved by the Quality Management Council (QMC) in August of 2005. The findings from the April 2005 Plan Dual Diagnosis study serves as historical data for this PIP.
To ensure consistency in data methodology across the measurement time periods the data recorded in this PIP has been aggregated in accordance with the member exclusions specified in the Final Ambulatory Follow-up Methodology, as the April 2, 2005 study report data do not accurately correlate with PIP data. The plan did revise all data from 2006 to the present to exclude all AA and NA appointments.
B. Activity II: Define the study question(s). Stating the question(s) helps maintain the focus of the PIP and sets the framework for data collection, analysis, and interpretation.
Study question:
Do targeted interventions increase the percentage of members who had a follow-up visit with a substance abuse practitioner within 7 calendar days of an inpatient discharge?
/ C. Activity III: Select the study indicator(s). A study indicator is a quantitative or qualitative characteristic or variable that reflects a discrete event (e.g., an older adult has not received an influenza vaccination in the last 12 months) or a status (e.g., an member’s blood pressure is/is not below a specified level) that is to be measured. The selected indicators should track performance or improvement over time. The indicators should be objective, clearly and unambiguously defined, and based on current clinical knowledge or health services research. /
Study Indicator 1
Percentage of members who had a follow-up visit with a substance abuse practitioner within 7 calendar days of an inpatient discharge. / Describe the rationale for selection of the study indicator:
The overall objective of the Co-Occurring Diagnosis PIP is to improve the quality of discharge planning for members with co-occurring diagnosis. The plan has received qualitative feedback internally from staff, as well as from external providers and advocates suggesting that members experience difficulty accessing treatment, receive psychiatric diagnoses inappropriately in order to access services, and do not always receive treatment and appropriate discharge plans related to substance abuse when hospitalized in psychiatric facilities.
Numerator: (No numeric value) / Total number of members who had a follow-up visit with a substance abuse practitioner within 7 calendar days of an inpatient discharge.
Denominator: (No numeric value) / Total number of members discharged with COD.
Exclusions:
·  Member refusal for services prior to scheduled appointment
·  Member readmits to an inpatient level of care within seven (7) days.
·  Discharges that indicated length of stays were less than two days and more than 30 days (calculated as the number of days elapsed between admit and discharge dates).
Baseline Measurement Period / January 1, 2006 – December 31, 2006
Baseline Goal / The goal is to improve upon the rates found in the plan’s April 2, 2005 study (65% for private facilities and 85% for RMHIs) to the 90% compliance threshold for both private facilities and RMHIs.
Remeasurement 1 Period / January 1, 2007 – December 31, 2007
Remeasurement 2 Period / January 1, 2008– December 31, 2008
Benchmark / 90%
Source of Benchmark / State contract, as reflected in the Final Ambulatory Follow-up Methodology.
D. Activity IV: Use a representative and generalizable study population. The selected topic should represent the entire eligible population of Medicaid members with system-wide measurement and improvement efforts to which the study indicators apply. Once the population is identified, a decision must be made whether or not to review data for the entire population or a sample of that population. The length of member’s enrollment needs to be defined to meet the study population criteria.
Study population:
The target population for this PIP is members with co-occurring diagnoses (COD) discharged after an inpatient stay – both acute psychiatric hospitalizations and residential treatment facility admissions. “Member” is defined as being enrolled in the program at the time of discharge or being eligible for benefits at the time of discharge. “Co-occurring diagnosis” (COD) is defined as having both psychiatric and substance related disorders /dependence related diagnoses. An acute inpatient stay is defined as having a length of stay of between two and thirty (inclusive) days. Members must be continuously enrolled through 7 days after discharge. The denominator is based on discharges, not members.
Exclusions:
·  Member refusal for services prior to scheduled appointment
·  Member readmits to an inpatient level of care within seven (7) days.
·  Discharges that indicated length of stays were less than two days and more than 30 days (calculated as the number of days elapsed between admit and discharge dates).
Applicable codes: 304.XX (drug dependence codes), 305.XX (Nondependent abuse drug codes), mental disorders-broad range of codes: 209-319.
E. Activity V: Use sound sampling methods. If sampling is used to select members of the study, proper sampling techniques are necessary to provide valid and reliable information on the quality of care provided. The true prevalence or incidence rate for the event in the population may not be known the first time a topic is studied.
Measure / Sample Error and Confidence Level / Sample Size / Population / Method for Determining Size (describe) / Sampling Method (describe)
The entire eligible population was used. No sampling techniques were utilized.
F. Activity VIa: Use valid and reliable data collection procedures. Data collection must ensure that data collected on study indicators are valid and reliable. Validity is an indication of the accuracy of the information obtained. Reliability is an indication of the repeatability or reproducibility of a measurement. /
Data Sources
[ ] Hybrid (medical/treatment records and administrative)
[ ] Medical/Treatment Record Abstraction
Record Type
[ ] Outpatient
[ ] Inpatient
[ ] Other ______
Other Requirements
[ ] Data collection tool attached
[ ] Data collection instructions attached
[ ] Summary of data collection training attached
[ ] IRR process and results attached
[ ] Electronic Medical Records
[ ] Other Data
Description of data collection staff (include training, experience, and qualifications): / [ ] Administrative Data
Data Source
[ X ] Programmed pull from claims/encounters
[ ] Complaint/appeal
[ ] Pharmacy data
[ ] Telephone service data/call center data